?Do comparisons betweenhospital support workersand hospitality workersmake sense?

Prepared for Hospital Employees’ Union • October 2001

BY MARJORIE GRIFFIN COHEN

MARJORIE GRIFFIN COHEN is an economist who is a professor of Political Scienceand Women’s Studies at Simon Fraser University.

She received her Ph.D. from York University and an M.A. from New York University.Before coming to SFU in 1991 her previous academic positions were at York Universityand at the Ontario Institute for Studies in Education. She has written extensively in theareas of public policy and economics with special emphasis on issues concerning women,international trade agreements, the Canadian economy, and labour. She is the author ofFree Trade and the Future of Women’s Work; Women’s Work, Markets and EconomicDevelopment; and a two volume series on, Canadian Women’s Issues: Bold Visions and StrongWomen.

Professor Cohen has served on several boards and commissions in British Columbiaincluding, B.C. Task Force on Bank Mergers; the B.C. Industrial Inquiry Commission onthe Fisheries; Board of Directors of B.C. Hydro; Board of Directors of B.C. PowerExchange. She is an activist who has served on the executive boards of the National ActionCommittee on the Status of Women, the Coalition Against Free Trade and the CanadianCentre for Policy Alternatives. She was also instrumental in establishing the CanadianCentre for Policy Alternatives in B.C. and was its first Chair.

AUTHOR’S NOTE: The author would like to acknowledge the valuable research, advice,and assistance of Margaret Manery and Nancy Pollak on this project.

Executive SummaryHIS PAPER CHALLENGES THE ASSUMPTION that privatizing hospital support workwould save the health care system money. Those in British Columbia who argue thatmoney would be saved if health care facilities focused on direct care medical servicesand contracted out “ancillary” “hotel-like” services to private firms frequently base

their claims on a three-page Fraser Institute report that compares the work of health care sup-port workers to hotel workers to prove their case.

The first part of this analysis examines the methods used in the Fraser Institute report. It showsthat the savings it claims are possible through paying hospital support workers the same ashotel workers are based on faulty research, heroic assumptions, and extrapolations that exagger-ate the wage differentials between these two sets of workers.

But the major problem with the Fraser Institute claim isthat it does not examine the actual work of hospital sup-port workers to determine whether this work is compara-ble to the work done in hotels.

In order to address this omission, the second part of thestudy examines the distinct skills, responsibilities, andworking conditions of hospital housekeeping staff, laun-dry workers, trades persons, food, and clerical workers. Itshows that the technical sophistication of hospitals and the responsibilities of support workersrequire a different set of skills and training than would be required in a hotel.

These skills are health care specific and are usually acquired through a long-term associationwith hospital work; something that is supported by the wages, benefits and job security provi-sions of the collective agreements covering 60,000 health and support workers in hospitals,long-term care facilities and community health services in B.C.

Health care support workers have considerable contact with patients/residents. This associationwith patients/residents brings challenges and risks that are unique to a health care setting. Thestudy shows, for example, how contact with chemicals and body substances makes the work ofmany support workers in hospitals and long-term care facilities considerably more hazardousthan that experienced by similarly titled workers in hospitality and other work places.

The main point of this analysis is that the level of skills, responsibilities and working conditionsof support workers are significantly different from those of workers in the hotel sector. Thesedifferences, combined with the health care specific on-the-job experience and training required,provide the basis for the higher wages for support staff in the health care sector.

The third section of this study examines experiences with the contracting out of hospital support work in the U.S. and at the Toronto Hospital. The aim is to assess whether privatizingthese so-called “hotel” services results in lower costs while maintaining the quality of existingservice. Although U.S. hospitals have gone further than those in Canada in privatizing or

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‘Fraser Institute claims are based on faultyresearch and exaggeratewage differentials’

“re-engineering” the provision of support services, the extent this has occurred is exaggerated bythose who advocate privatizing these services in B.C.

However, among those U.S. hospitals that have embarked on “re-engineering,” the expectedbenefits in lower costs frequently do not occur. In fact, institutions like the American HospitalAssociation caution about the probability of increased costs and reduced reliability of perfor-mance through hospital re-engineering and privatization.

Similarly, an examination of the experience of the Toronto Hospital (part of the UniversityHospital network) with contracting out food services and stores indicate that the promised benefits from outsourcing have not been achieved. The recent reversal on contracting out foodservices indicates the degree of dissatisfaction with this experience by both patients and staff. Ingeneral, surveys conducted by hospital management indicate that there is an unusually highdegree of staff and patient dissatisfaction with the hospital – a dissatisfaction that can be corre-lated to the re-engineering that occurred.

In the fourth section, this paper shows that the advocates of privatizing support services inhealth care facilities have a larger target – that is, the privatization of hospitals themselves.Evidence from the U.S. shows that hospital privatization leads to greater costs and lower efficiencies, with the greater costs coming partially from the provision of more expensive “hotelservices.”

The study concludes by pointing out that the rush to privatize too often occurs when the empir-ical evidence points in the opposite direction. The hidden costs of privatization to both patienthealth and staff morale should make administrators extremely wary of calls for privatizing hospital services. Since the current direction of health care reform indicates an increasing aware-ness of the integrated nature of patient care, it would be wrong, through privatization, to splitclinical and non-clinical health care work as though they are disconnected. Privatization of anypart of the health care system will fragment care and place barriers in the way of teamwork andcollaboration.

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I. IntroductionHIS PAPER IS A RESPONSE TO RECENT CALLS for alleviating the funding crisis inhealth care by limiting public expenditures to direct patient care services. Proponentsof this view argue that money can be saved if health care facilities focus exclusively ondirect patient care, and contract out so-called “ancillary” or “hospitality” services. The

assumption is that labour costs for service workers in private firms are lower than in the healthcare system. The savings from contracting out support work, it is argued, would free upresources to meet the shortfall in funding for physicians, nurses and other direct care staff.

In B.C., very influential people have taken up this argument. Vaughan Palmer, political colum-nist for the Vancouver Sun, for example, blames the wages paid to “nonprofessional” health careworkers for a situation that deliberately “starved the acute care portion of the health care systemof resources.”1 Similarly, former British Columbia Medical Association President Ian Courticetargets unionized “nonessential” health care workers for driving up hospital costs and calls forthe privatization of this work.2 And Fred McMahon of the Fraser Institute claims that unionizedhospital workers who are not health care professionals earn 10 to 20 per cent more than peopledoing the same job in the private sector.3 McMahon’s claim is based on an earlier FraserInstitute paper that is worth examining because its assertions are repeated frequently enough tohave acquired some status as a genuine study.

The Fraser Institute “study” on labour costs in the hospital sector is a slim, three-page 1995report produced by Cynthia Ramsay.4 In it the Fraser Institute estimates that B.C. could save$198 million a year, or 6.8 per cent of the total annual spending at the time on acute care hospitals in the province if “non-technical” hospital workers were paid wages equal to their pri-vate sector counterparts.4 While the Fraser Institute piece does not spell out the method bywhich the wages of these workers would be decreased, the two main possibilities for achievingthis savings would be through wage rollbacks and/or privatization through contracting out nondirect care services.

This report will initially examine the methodology of the Fraser Institute report to understandthe validity of its claims. This will be followed by a detailed examination of the nature of support work within health care facilities, work that the Fraser Institute considers comparableto support work in hotels. The main point of this analysis is to determine if the work in the twoworkplaces is, in fact, the same or similar.

The paper will also discuss the broader implications of privatization of “hotel-like” hospital services based on the experiences that have been documented in the literature and throughinformation obtained in interviews and documents from Toronto Hospital, part of Canada’slargest health care facility, the University Hospital Network. The Toronto Hospital’s experiencehas been included because it is one of the most prestigious teaching hospitals in Canada andhas positioned itself as a leader in providing alternate delivery strategies through re-engineering,outsourcing and contracting out.

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1 Vaughan Palmer, “NDP Policies Depleted the Health System,” The Vancouver Sun, 4 November 2000.2 “Redistribute Funds and Privatize Non-Essential Services, Says BCMA President,” Sounding Board Vancouver, 29 February 2000.3 Fred McMahon, “Doctor Problem,” The Vancouver Sun, 15 January 2001.4 Cynthia Ramsay, “Labour Costs in the Hospital Sector,” Fraser Forum (November 1995): 17.

II. The Fraser Institute study: cost savingclaims don’t measure up

N 1995 CYNTHIA RAMSAY PRODUCED a very simple study that examined the wagerates paid to 17 specific Hospital Employees’ Union jobs at Royal Columbian Hospitalin New Westminster using negotiated collective agreement wage rates at April 1,1995. She compared these to “similar” jobs and wage rates for Hotel Restaurant and

Culinary Employees (Local 40) hotel workers outlined in that union’s Nov. 1, 1991 collectiveagreement.5

According to the comparison of jobs deemed to be equivalent to those in hotels, Ms. Ramsayconcluded that if this hospital paid the same rates as those earned by unionized hotel workers itwould save more than $2.6 million a year.

This comparison covered only 372 of the 776 “non-techni-cal” support workers at the hospital. Ms. Ramsay then esti-mated that because the average wage differential of the 17jobs she examined was $3.94 per hour, if the same differ-ential were applied to the other non-technical workers (theworkers in jobs that were not comparable to hotel work-ers), the hospital would save an additional $2.8 million ayear. The total annual savings for this hospital would be$5.4 million a year, or 3.3 per cent of its total budget.From this she assumed that other hospitals would alsohave the opportunity to save about three to four per centof their budgets by paying non-medical workers wagessimilar to those paid in hotels.

With these calculations Ms. Ramsay continued to extrapo-late to give an idea of the savings that could be achieved if all of the HEU “non-technical” mem-bers throughout the province were paid hotel wage rates.6 Using the assumption that the distri-bution of “semi-technical and non-technical” workers was the same in all hospitals, she estimat-ed that about 74 per cent of the total HEU membership would fall into the group to be paidless. All together the province could save, according to these calculations, $197.8 million a year,or 6.8 per cent of the total annual spending of acute care hospitals at the time.

ASSESSMENT: The Fraser Institute piece makes several heroic assumptions in its process of extrapolation that considerably exaggerate the wage differentials between hospital andhotel workers. (See Appendix I for wage comparisons between HEU, hotel workers andother workers in the public sector.)

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FAST FACTS• Unlike hospitals, hotel

food servers and house-keepers earn at least $4an hour in tips

• The “study” comparesticketed trades jobs with hotel maintenancepositions

• Detailed job evaluationsweren’t conducted

5 Interestingly, in the text of Ms. Ramsay’s study, she refers to 18 job classifications, although her chart only includes 17. This is one indication of the sloppiness of this “study.”

6 She excludes technicians and others “who require specific medical knowledge to perform their duties” from the group of workers to receive lower wages.

The incorrect methods of the Fraser Institute study include the following:

• The Fraser Institute conflates full-time and part-time work, calculating all employees’wages as though they worked full-time. According to HEU essential service statistics onfull-time equivalents in each job classification, there were 201 FTEs in the 17 job classifi-cations at Royal Columbian Hospital, rather than 372 as used in the Ramsay calcula-tions. In just this one calculation Ms. Ramsay overstates the wage differential by $1.2million, or almost half the savings she claims could be achieved at the outset at RoyalColumbian by paying the workers the same as hotel workers in the 17 job categories.

• The Local 40 wage rates she uses are not indicative of the total income hotel workersreceive for their work. In particular, food servers and housekeeping aides normallyreceive gratuities in addition to their basic wage.

An average of these gratuities cannot be precise, since they would vary by type of hoteland circumstances. Food servers in high-end hotels, for example, receive several hundreddollars a day in gratuities in addition to their wages. But for both food servers andhousekeeping aides, gratuities in the amount of at least $4 per hour would not be out ofthe ordinary.7 This would make hotel and hospital compensation for this type of workabout the same. The main difference is that hotel clients, rather than the employer, paysthe gratuities.

• There are two significant problems with the information the Fraser Institute uses forcomparing trades classifications. First, the HEU wage rates are for ticketed journey persons while the Local 40 comparisons are not for ticketed trades positions, but formaintenance workers. The qualifications of the two groups are quite different.

Second, according to Local 40 hotels, even large luxury hotels do not directly employtrades people. While hotels normally do directly employ maintenance workers, whenqualified electricians, plumbers and painters are needed the hotels hire private contrac-tors. In fact, the hotels would not be paying Local 40 rates for most of the work in thiscategory, but would be paying standard union rates that are higher than those stipulatedin the HEU contract (see Appendix I).

Since the greatest wage differentials in Ms. Ramsay’s calculations are for work in the“trades” categories, the misrepresentation of how this type of work is performed in hotelscreates considerable inaccuracies in the savings that could potentially be made. Her claimof a $9.50 differential for electricians, $8.67 for plumbers and $8.46 for painters, pro-duces a potential savings of $390,000 a year for Royal Columbian Hospital just forreducing wages of trades people to hotel levels. The fact that hotels do not pay the wagesshe claims for this type of work makes this entire assertion false.

• As HEU has noted elsewhere, the province-wide savings calculated by the FraserInstitute study are based on an assumption that 74 per cent of the total HEU membersare “non-technical” workers and could, therefore, have wage rates reduced an average of$3.94 an hour (based on the average calculated wage differential in 1995).

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7 In fact, this is an extremely conservative estimate. Cleaners in high-end hotels can expect to earn between $30 and $60 a dayin tips, in addition to their negotiated salary.

There are many problems with the kinds of extrapolation that arises from the failure toanalyze the work requirements of the specific jobs in question. The most obvious prob-lem is the assertion that a large proportion of HEU members are workers whose jobs donot require “specific medical knowledge.” HEU notes that a classification profile of itsmembers in acute care shows that 45 per cent work in direct patient care, 17 per centperform clerical work requiring medical knowledge and two per cent work in medicalrecords. This means that only 34 per cent of HEU workers (rather than 74 per centcited) would fall into the Fraser Institute’s so called “non-technical” classification.8

• There is also a problem with the methodology Ms. Ramsay uses to calculate the “average”hotel hourly wages. The Local 40 collective agreement stipulates wage rates for specifichotels and unless one knows how many people were working at each hotel in each occupational category, it would not be possible to construct an “average” wage rate in the hotel industry.

The figures that appear in the Fraser Institute paperseem to be constructed by simply adding the wagespaid in each of the hotels and dividing them by thenumber of hotels, without reference to the size ofthe workforce in each hotel. This is an extremelyrough and unreliable calculation of the “averagewage” for each occupation in the hotel sector.

• Finally it must be noted that the Fraser Institute claims relate to wage rates that are notcomparable because they deal with different time periods. The Fraser Institute study useshotel wage rates based on a 1991 agreement that had expired, and compares these withnewly negotiated 1995 wage rates for HEU.9

In fact, the Fraser Institute study misrepresents the dates of the Local 40 collective agree-ment. The actual dates, according to the contract, were from Nov. 1, 1991 to Feb. 28,1995, although the Fraser Institute claims it dated from Nov. 1, 1991 to Nov. 1, 1995.10

There is a clear lack of correspondence in the dates used in comparing the wages acrossthe two unions.

The method the Fraser Institute has used to calculate wage differentials between hotelworkers and hospital support workers seriously exaggerates the difference between thesetwo groups of workers. But the major problem with the Fraser Institute study is that itpresents job comparisons in very blunt ways, ways that are not characteristic of howwage rates comparisons are usually done. That is, the Fraser Institute has not examinedjob classifications in hospitals and compared them with hotel workers’ jobs, but hasmerely assumed that they are the same.

Normally, job comparisons are undertaken by assessing four categories for comparison:the skills, effort, responsibilities and working conditions associated with specific posi-tions. In this way people with different job titles but similar work can be compared and

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8 McIntytre and Mustel, HEU Membership Profile Survey, 2000.9 See Collective Agreement between the Greater Vancouver Hotel Employers’ Associations and Hotel, Restaurant and Culinary Employees

and Bartenders Union, Local 40, 1 November 1991.10 Ramsay, 18.

‘The Fraser Institutehas merely assumedthat job classificationsare the same’

their appropriate wages assessed. Also people with similar job titles can have very differ-ent responsibilities and working conditions that justify different wages in different workplaces.

Without an examination of the work actually being done within hospital and hotel settings, a comparison such as the Fraser Institute’s cannot achieve reliable results. Thefollowing section examines the nature of support work in health care facilities comparedto hotels. The evidence points to very substantial differences in the nature of supportwork in hotels and hospitals, and provides a basis for understanding why wage rates arehigher in health care facilities than in hotels.

III. Examining support work in hospitals HE INFORMATION FOR THIS SECTION relies heavily on interviews undertaken at avariety of hospitals and long-term care facilities with health care support workers,nurses, doctors and other hospital personnel. (See Appendix II for information aboutthe methodology of this paper.) While there is

an extensive literature on the working conditions, skilllevels, and responsibilities of the medical and technicalstaff in hospitals, nothing comparable exists for otherhospital personnel.

The few references to food servers, laundry and clericalworkers in the recent literature focus on either healthand safety issues or contracting out, and make little ref-erence to the specific conditions faced by support work-ers in health care sector.11 The work of hospital-basedtrades persons has not been examined at all.

There are, at the same time, a small number of signifi-cant studies on the work of cleaning staff in hospitals inMontreal.12 These studies raise many specific issues thatwill be discussed in subsequent sections. In general thefindings from these studies point to the fact support services in hospitals are crucial to the cor-rect functioning of a hospital and that too often support workers’ skills are undervalued becausetheir work is not visible or acknowledged by the professional and administrative staff.

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11 See Wayne Jensen, “Contracting Out Building Cleaning Services at the National Hospital Of Denmark,” Contracting outGovernment Services: Best Practice Guidelines and Case Studies, no. 20 (1997): 27-30; David J. Gawkrodger, Margaret H. Lloyd, andJohn A.A. Hunter, “Occupational Skin Disease in Hospital Cleaning and Kitchen Workers,” Contact Dermatitis 15 (1986):132-135;M.A. Borg and A. Portelli, “Hospital Laundry Workers – An At-Risk Group For Hepatitis A?” Occupational Medicine 49, no. 7, (Sept.1999): 448-50.

12 See Karen Messing, “Hospital Trash: Cleaners Speak of Their Role in Disease Prevention,” Medical Anthropology Quarterly 12, no.2, (June 1998): 168-187; Karen Messing, Celine Chatigny, and Julie Courville, “ ‘Light’ and ‘Heavy’Work in the Housekeeping Serviceof a Hospital,” Applied Ergonomics 29(6), 1998, 451-459; Daniel Tierney, Patrizia Romito, and Karen Messing, “She Ate Not the Breadof Idleness: Exhaustion Is Related to Domestic and Salaried Working Conditions Among 539 Quebec Hospital Workers,” Women &Health 16, no. 1 (1990): 21-41.

FAST FACTS• Marjorie Cohen conducted

detailed interviews with support workers and other health care professionals

• There’s limited academicliterature on the role ofsupport workers

• But one key study sayssupport workers’ skills are undervalued

The following examination of the distinct skills, responsibilities and working conditions ofhousekeeping staff, laundry workers, trades persons, food and clerical workers will show thatthe work of support staff in health care is considerably more complex than is normally under-stood, and constitutes work that is substantially different from that undertaken within hotels.

An examination of support work in health care shows how important this work is to the effi-cient running of hospitals and, in most cases, to the health of patients. The distinction between“caring” work and the work of the support staff is not as clear-cut as is often assumed; the workof the “non-technical” support staff is directly related to patient care. In addition, and particu-larly noteworthy, is the fact that all health care support occupations require considerable healthcare specific knowledge, skills and on-the-job experience and training.

HOUSEKEEPING/CLEANING: The work of housekeeping and cleaning staff in health carefacilities cannot be easily compared to the work performed by housekeeping staff in hotels.It differs in a number of respects including the standards of cleanliness required, the complexity and technical sophistication of the physical environment and health hazard risks for housekeeping/cleaning staff. In addition, the contact with patients makes the workof housekeepers in hospitals quite distinct from housekeepers in hotels.

RESPONSIBILITIES, SKILLS,AND TRAININGCleaners/housekeepers in health care facilities follow stringent and detailed cleaning proce-dures that vary depending on the type of facility and the specific area in which they work.Hospitals prefer to hire people who have completed the Vancouver Community CollegeInstitutional Aid Program.13 The three-month cleaner program (five months for ESL stu-dents) deals with all aspects of cleaning, with particular emphasis on health care cleaning,sanitizing and chemical use. Cleaners also receive additional on-the-job training in emer-gency codes related to incidences of patient violence, evacuation procedures, and fires.

Different hospital units, such as the operating room and other areas where patients are particularly vulnerable, require special cleaning techniques and additional training. Thistraining is usually provided by a nurse or other qualified health care professions. What follows is a description of the specialized nature of cleaning in specific hospital units.

Operating Rooms:Operating rooms require the highest standards of cleanliness and must be left sterile andimmaculate. According to one worker, “cleaning minute drops of blood requires a mind setnot obvious to anyone who is not trained to clean this area.”

The housekeeping staff work around sensitive and expensive equipment and yet need tobe fast and efficient. In some cases there is only a 15 minute turn-around time betweenpatients, and cleaning staff are frequently working while doctors and nursing staff are getting organized and bringing in equipment for the next patient. No time allowances are

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13 See the Vancouver Community College Building Service Worker Program Outline for a detailed description of the cleaning program.

made for the type of surgery performed, something that puts added pressure on the clean-ers since some types of surgery require a great deal more cleaning than others. Blood,bones, bone chips, teeth, tissue and fat fall on the floor and make cleanup dangerous andunpleasant.

Dialysis Units:Patient turnover rates in dialysis units are very high. There are serious sanitation issues toconsider in this unit because it is a place where the risk of cross-infection is high. The timepressures create stressful work situations for the cleaners – one worker at VancouverGeneral Hospital says she changes 22 beds in an hour. As soon as a patient leaves, thesheet and pillowcase are replaced, all spills cleaned up and linen bags removed.

Emergency Departments:These departments experience very high turnover rates that create considerable stress forcleaners because the cleaning demands are heavy. Stretchers that are often covered withblood, vomit or other bodily fluids are difficult toclean quickly and must be washed between eachpatient. VGH Emergency has a “quiet room” for vio-lent patients that is often soiled by feces, urine, bloodand vomit that cleaners must deal with regularly.

Radiation Rooms:Cleaning radiation rooms requires protective clothingand special cleaning with cleansers like Isoclean. Aspecial protocol exists for using this material. The process is very time-consuming and yetthe additional time required is not factored into the cleaner’s schedule. After the cleaning isfinished, the room is monitored for radiation. If any “hot spots” are found, the room mustbe cleaned again.

Burn Units:Intensive cleaning is required in burn units because the risk of infection to patients is par-ticularly high. Everything in the room, including blinds, wall and all surfaces are carefullycleaned more regularly than in most other units.

Infection Control – Antibiotic Resistant Organisms (ARO):The increasing prevalence of organisms that are resistant to antibiotics, such as MethicillinResistant Staphylococcus Aurous (MRSA) and Vanconycin Resistant Enterococcus (VRE), isa serious problem that has direct consequences for cleaning standards at health care facili-ties. As a result of the difficulty of treating these diseases, hospitals focus on preventing thespread of organisms through specific cleaning protocols. MRSA, for example, can live out-side the body for a lengthy period of time, so it is relatively easy to pass it from one patientto another, unless special precautions are taken. In this sense, controlling AROs is primari-ly a housekeeping issue.

Special protocols exist for cleaning rooms of MRSA and VRE patients. Everything in theroom, including the bed, wall, floor, furniture and privacy curtains around the patient’s

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‘Intensive cleaning inburn units is requiredbecause the risk ofinfection is high’

bed, are cleaned with the disinfectant Phenokill and bleach. Cleaning staff are conscious ofand trained to deal with the threats to patients through the spread of ARO organisms andof the need for special precautions when cleaning.

In summary, hospital housekeeping staff must have specialized knowledge specific to a healthcare site and unit where they work, and are required to follow complex and exacting cleaningprotocols. They are very conscious of the risks involved in their work and of the very seriousconsequences of making an error.

PATIENT CONTACTHousekeepers are well aware of the significant role they play in the well-being and recov-ery of patients and residents. According to one worker at VGH, “We are the frontlineagainst infection. We are the ones who make the hospital safe.”

While housekeeping staff are not directly responsible for patient care, they see patients fora minimum of 20 minutes a day. Their presence in the room often gives people who arelonely – particularly out-of-town patients – needed support. They also play an importantrole in handing patients blankets and out-of-reach items, opening drink containers, gettingpersonal items, notifying a nurse of problems and conversing with patients.

Sometimes patients have legitimate needs that have not been addressed, making the obser-vation of the housekeeper particularly important to the patient’s well-being. One house-keeper described working in a room where the patient sat shivering, without slippers andlittle clothing on. He gave the patient a blanket and felt appreciated because “she smiled.”

Since interactions with patients are not a direct responsibility of the housekeeping staff, thetime workers spend doing this type of work is “stolen” from their normal jobs and timebecomes a difficult issue. However, some of the housekeepers, particularly from long-termcare facilities, report that their administrators do recognize the value of the time theyspend with residents and have incorporated this into the workload.

In addition some of the newer models of care, in both long-term and acute care, combinethe job requirements for housekeepers and care aides. The idea is to provide more stableand familial care to the patient/resident by assigning staff to work with fewer residents butrequiring them to do a broader range of activities with those patients/residents (i.e., bothcare and housekeeping).

Housekeeping staff frequently become close to patients/residents and their families and, asa result, experience a great deal of emotional stress through their job. They see pain, fearand suffering and are affected by the trauma of the patient and their families.

In particular, staff mentioned the emotionally draining nature of working with people whohave been abandoned by their families and friends, young people who are critically ill, allthe patients/residents who die, sometimes while the cleaners are in the room, and the trau-ma of finding suicide victims. One cleaner in a long-term care facility described the pain ofcleaning out “the personal possessions of someone who has died – it is like wiping awaythe patient’s life.”

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All of these interactions with patients make the work of hospital cleaners – even in thenormal routine of cleaning patients’ rooms – quite different from the work of a cleaner in ahotel. The cleaning is more demanding and complicated because patients are often presentand require additional support and assistance.

HEALTH HAZARDSHealth care workers are recognized to have particularly higher exposure rates to health andsafety risks on the job that the general work force. According to the Workers’ Compen-sation Board, cleaners/housekeepers in hospitals and long-term care facilities have injuryrates that are more than four times that of the average industrial worker.14

The occupational hazards associated with housekeep-ing staff can be grouped into four categories. These are:

• biological and infectious hazards;

• chemical hazards;

• environmental and mechanical hazards; and

• workload hazards.15

These occupational hazards are specific to health careand not hotel housekeeping work. In themselves theywould justify a substantial wage difference betweenhospital and hotel housekeeping staff.

Biologic and Infectious Hazards:Cleaners in health care facilities are constantly exposed to infectious substances. Some ofthe risks are built into the job, simply through contact with patients or bodily fluids. Otherbiologic and infectious risks arise from the improper disposal of needles.

One worker who was interviewed has had 13 needle sticks. These needle sticks areextremely dangerous because they expose health care workers to blood-borne pathogenssuch as HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV).16 A major study ofoccupationally-acquired infections in health care workers found that there is a bigger riskfor Hepatitis B among cleaning service employees than among nurses.17

According to a medical microbiologist at an acute care hospital who was interviewed forthis study, the biggest health risks for hospital cleaners come from contact with TB, chick-enpox, respiratory tract illness, and blood borne pathogens. It is also worth noting that therecent resurgence of tuberculosis has profoundly altered views about the risk of tuberculo-sis in health care workers, particularly since of the emergence of multi drug-resistantstrains of TB.18

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14 Health care cleaners’ injury rate is 17 per cent compared with a 4.1 per cent injury rate for workers in all industries. (Worker’sCompensation Board Statistical Services, special run for the Hospital Employees’ Union, 1999).

15 Ibid., 249.16 Denise Cardo and David Bell, “Bloodborne Pathogen Transmission in Health Care Workers,” Infectious Disease Clinics of North

America 11, no. 2 (June 1997): 331-346.17 Kent A. Sepkowitz, “Occupationally Acquired Infections in Health Care Workers, Part II,” Annals of Internal Medicine 125, no. 11

(1996): 918.

FAST FACTS• Cleaners follow stringent

procedures. They are thefrontline against infection

• Housekeepers see patientsat least 20 minutes a day

• They face a range of biological and workloadhazards, and sky highinjury rates

Chemical Hazards:Chemical exposure can occur through inhalation, ingestion and absorption through theskin or mucous membranes. Common hazards include exposures to disinfecting or steriliz-ing agents such as glutaraldehyde and ethylene oxide, chemotherapeutic agents, wasteanesthetic gases and latex. 19

Housekeeping staff are in constant contact with chemicals. Some chemicals are particularlydangerous if they are airborne and staff need to know under what conditions they can and cannot be used. The housekeeping staff interviewed for this study indicated adversereactions to various types of chemicals including skin dermatitis and allergic reactions tocleaning agents such as Phenokill. 20

In addition to chemical exposure, housekeeping staff also have to deal with hazards ofphysical agents in the environment such as exposure to body fluids from patients receivingmetabolized therapeutic nuclear radiation. In some hospitals cleaning staff have also takenover responsibility from nurses of cleaning up mercury spills.

Environmental and Mechanical Hazards:Housekeeping staff have very high on-the-job injury rates. Lower back, shoulder and neckinjuries are most common.21 The housekeeping staff specifically mentioned problems withthe weight and contents of linen bags. This is a problem especially in the Lithotripter area(treatment for kidney stones) where linens and towels are soaking wet. Also frequentlymentioned are problems that arise with electric and operating room beds that are difficultto clean because of their many moving parts. The weight of these beds (up to 1,000 kilos)makes them very heavy to move when cleaning the floor, even though they are on casters.

Workload Hazards:The workload in health care facilities has intensified over the 1990s for a variety ofreasons, including greater patient acuity, early discharges and higher patient turnover.Without increases in housekeeping staff, this has made it difficult to complete work onschedule, or to at least do it well and on time.

This creates great stress among the staff because they are acutely conscious of the highstandard of cleanliness that is essential in the hospital and that is expected of them. Highworkloads are exacerbated by the increased cleaning needed for MRSA or VRE patientrooms, but no additional time has been allocated for the work. A worker at St. Vincent’s

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18 Dick Menzies, Anne Fanning, Lilian Yuan, and Mark Fitzgerald, “Tuberculosis Among Health Care Workers,” New England Journalof Medicine 332 no. 2 (Jan. 12, 1995): 92-98; J. Louther, P. Rivera, J. Feldman, N.Villa, J. DeHovitz, and Kent A. Sepkowitz, “Risk ofTuberculin Conversion According to Occupation Among Health Care Workers at a New York City Hospital,” American Journal ofRespiratory Critical Care Medicine 156, no. 1 (July 1997): 201-5.

19 Bonnie Rogers, “Health Hazards in Nursing and Health Care: An Overview,” American Journal of Infection Control 25 (1997): 252.20 See Gawkrodger et al, 132-135.21 According to the Workers’ Compensation Board, workers in acute care hospitals in 1999 had an injury rate more than 70 per

cent higher than that of the average worker in all industries.Those in long-term care facilities have injury rates almost two and ahalf times greater than the average worker (WCB Statistical Services, special run, 1999).

Hospital in Vancouver talked about the increase in workload as a result of increased eyesurgery – on days when there are extra surgeries her workload doubles.

Restructuring in many health care facilities also has increased the workload because of staffcutbacks or the elimination of positions for orderlies, escorts, transport staff and licensedpractical nurses. These cutbacks have consequences for housekeeping staff because theyusually have to pick up some of the work. In addition to the extra work, restructuring alsonegatively effects the stress level of professionals and patients and this stress seems tobecome, as one worker said, “infectious.”

In addition to problems with workload is the stress and physical injury caused by the highrate of physical aggression and violence against workers in health care. The violencehousekeeping staff encounter can come from patients or family members who misdirecttheir anger at staff. The emergency room is an especially dangerous area, as are long-termcare facilities and special units in the hospital where dementia patients are cared for.

HOTEL CLEANERS: The range of hazards health care workers encounter are simply not comparable to work hazards in hotels. An interview with a representative of Local 40revealed that there are health and safety issues for hotel workers, but these are not as serious as they are for workers in health care facilities. Room attendants (those who cleanthe rooms) tend to get back injuries and injuries associated with repetitive motion, butthey are not routinely exposed to the hazards from patients or from dangerous substances. Also, since they have little contact with hotel guests, they experience few incidents of harassment and virtually no incidents of violence.

CLEANING STANDARDS IN HOTELSCleaning standards in hotels are radically different from those in health care facilities, andthis in itself makes the nature of hospital cleaning substantially different. While no system-atic studies of hotel cleanliness have taken place in Canada, there is information aboutbrand name hotels in the U.S., many of which have establishments in Canada. Scientists atthe University of Arizona have studied and published on this issue and, as a result, lack ofhotel cleanliness has gained considerable attention.22 Dr. Charles Gerba, a microbiologistand the primary author of the University of Arizona study, examined the cleanliness ofhotels in the U.S. for the ABC News program, Prime Time Live.23

The study analyzed hotel and motel rooms throughout the U.S., testing respected namebrand places and luxury hotels for coliform bacteria and E coli.24 All the bedding showed apresence of urine or semen and these substances were also present on carpets, upholsteredfurniture and on the walls. Semen stains were even found in a $700 a night suite. Fecalbacteria were found in bathrooms, but also in peculiar places such as on the telephone andthe TV remote control. The assumption was that the same cloth was used for cleaning thebathroom as was used for the rest of the room.

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22 Charles P. Gerba, Moyasar T.Yahya,Timothy M. Straub, and Jenna M. Cassells, Microbiology of Hotel Bathrooms, (Tucson: Universityof Arizona, Department of Soil,Water and Environmental Science, 1990).

23 Gina Pampinella and Sylvia Chase, “Clean Sweep,” Prime Time Live, ABC News, 11 March 1998.24 The presence of coliform bacteria indicates presence of filth. E. Coli indicates the presence of fecal matter.The average price for

the rooms examined was $160 U.S. a night.

Dr. Gerba noted that disinfectants were not used when cleaning. He pointed out that bacteria pseudomonas present in these rooms may not be very dangerous to healthy people, but are a telltale sign of a dirty room and it was found everywhere at high levels –even in ice machines and coffee pots.25

The main conclusion to draw from the U.S. study is that hotel cleanliness is of a differentorder from that essential in a hospital. People may be disgusted from contact with semen,urine and fecal material they encounter in hotels, but, if they are healthy, they probablywill not get very sick. However these kinds of conditions cannot be replicated in a hospitalbecause they are breeding grounds for organisms that could be lethal for someone who isill.

LAUNDRY WORKERS: Laundry work associated with health care facilities carries responsibilities and risks that differ substantially from hotel laundry work. The laundry requirements of specific hospital units are unique and requirespecialized knowledge and skill acquired by workers through experience and training on-the-job. Similarly, the distinct substances encountered in a hospital laundry relate to bodily fluids and contact with them makes this type of workespecially hazardous.

Much of the employee information for this section comesfrom laundry workers at the Tilbury Regional HospitalLaundry in Delta. This laundry is a publicly owned facilitythat processes about 28,000 kilograms of hospital linensevery day for many Lower Mainland health care facilities. In general the workers describeTilbury as a state-of-the art laundry that is well managed, efficient and highly mechanized.

RESPONSIBILITIES AND SKILLLaundry workers require distinct skill to deal with the special laundry needs of differenthospitals and specific units within health care facilities. For example, isolation laundry iswashed in separate manually loaded machines. Workers must be especially conscious ofheavily stained items that require treatment with appropriate chemicals and must bewashed often and then rewashed. Different fabrics cannot always be mixed because of thedifferent heat and chemicals used in the cleaning process.

Special training and skill are needed for the requirements of operating room laundry.Surgical gowns and other operating room supplies are laundered separately because theyare made from microfibre, a specialized fluid-resistant material. Operating room linens(gowns, sheets, coverings, pants), in particular, require higher levels of cleanliness andscrutiny than laundry associated with most other units.

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25 The problem of poor hygiene in hotel rooms has spawned a new product that allows hotel guests to gage the cleanliness oftheir rooms. It is a Rest Assured Personal Inspection Light – a 4.8-watt, battery operated ultraviolet tool designed to expose driedbodily fluids. (Jane Costello, “This gismo could just bring out a little compulsiveness in us all,” The Wall Street Journal, 13 October1998, Interactive Edition, B1); Hanna Rosin,What Work: Germ Warfare,” The Washington Post, 9 May 1999, Final Edition,WO6.

‘Special skills areneeded for therequirementsof OR laundry’

A special operating room floor is designed to deal with clean surgical linens. On this floorlaundry is separated into categories and checked very carefully for lint and any loosefibers. This is an essential task to ensure that patients are not infected by stray particlesduring surgery. Each microfibre gown and sheet or drape is inspected on a light-table forholes, tears and other defects and is either repaired or recycled.

Folding operating room linens into surgical bundles is a skill that requires specializedtraining to meet the Canadian Standards Association’s (CSA) International standard.Microfibre surgical gowns require special attention to ensure that the gown remains sterilewhen taken out of the bundle prior to surgery. According to one worker, “The gown isworn after doctors have scrubbed for surgery so the exterior of the gown must not come incontact with anything. If things are not folded correctly, the gown is discarded and thedoctor takes a new one.” Similar care is taken in the special folding of surgical sheets.

Particular skill and diligence are also necessary when assembling surgical bundles for different operating rooms. There are 21 types of surgical bundles assembled for St. Paul’sHospital alone. For example, a standard bundle for transfusion includes a huck towel, anOR gown and six single towels wrapped in a microfibre sheet.26 A burn unit bundleincludes four pillowcases, one fitted sheet, one flannelette sheet, one bed sheet, four bathtowels, one cellular blanket, and one microfibre wrapper.

According to one laundry worker with 20 years experience, “It takes weeks to learn the job and maintain continuity, but it takes months to learn to do the job efficiently.”

The importance of an efficient laundry service to the effective work of a hospital cannot be over estimated. A supervisor at one hospital which had contracted out its laundry to aprivate, commercial laundry, explained some of the problems with the privatized service,“When aprons were sent out, they would come back so tangled up that it would takehours to sort out – they had to be thrown out. Rags and uniforms sent out would nevercome back, or if they did they were tangled up with underwear, socks and pads that didn’tbelong to anyone in the facility. Uniforms would be washed with heavily soiled items, andcome back unwearable. Staff would have to take their uniforms home to be washed.”

Ultimately the problems this hospital experienced were so serious that the laundry workwas brought back in the hospital itself.

HEALTH HAZARDSBecause of the nature of the linens being washed, the workers at Tilbury are exposed tohazardous and infectious substances. In fact, hospital laundry workers are among the mostsusceptible of all health care workers to an array of specific infections.27 They are particu-larly susceptible to salmonellosis and scabies.28 Since these workers have no direct contactwith infected patients, the contamination is almost always transmitted through contaminat-ed linen.29

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26 A “huck towel” is a small terry towelette.27 Sepkowitz, 922. Included among those most at risk for infection are laboratory personnel, veterinarians and animal handlers,

pathologists, surgeons, dentists, anesthesiologists and laundry workers.28 Lice, scabies, and crabs are common. At Tilbury an exterminator disinfects the area around the washers once a week.29 Sepkowitz, 920.

A British study found that laundry workers who consistently handled dirty linen had high-er odds of contracting Hepatitis A than colleagues who handled only clean items. Theyconcluded that the “increased exposure of hospital laundry workers to potentially infectedlinen can constitute a risk of occupational Hepatitis A.”30

At Tilbury all 28,000 kilograms of laundry, which often is soaking wet, must be sorted byhand each day. The workers who do this “first assault,” or “soil sort” must individuallyhandle each item and sort it according to whether it belongs in various bins designed forregular (automated) laundering or if they should be put in the red bio hazard sling bagsfor isolation (manually loaded) laundering. The laundry bags weigh 5.5 kilos empty andmore than 90 kilos when full.

The workers in the soil sort and the isolation laundry are in the most hazardous workareas. Generally, in the hospital bio-hazardous material is kept separate from other garbageand other items, (i.e., diapers) which are supposed to be cleaned prior to disposal. Butoften these items end up in linen bags and are left to the laundry to sort.

During the sort workers find surgical instruments, such as scalpels and blades, IV sharps,and syringes. According to one of the workers, “Needle sticks are surprisingly uncommonbecause everyone is trained to watch for these kinds of things. But every day you worryand talk about the dangers of needles.” Clearly the significance of training and experienceon the job is crucial to keeping the injury rates down.

They also find colostomy bags, soiled dressings, and body parts, including umbilical cordsand internal tissue. One worker found a placenta wrapped in a bag. All of these are poten-tially dangerous to workers. Microfibre linens associated with surgical procedures present aparticular problem because the fabric is fluid resistant. These microfibre items are some-times full of bodily fluids or coagulated blood. One worker said one of these items “canresemble a body part but is just a big clump of blood.”

In concluding this section it is worth noting that the health care specific knowledge, extensive on-the-job training requirement and risk hazards in hospital laundry workmakes simplistic comparisons with hotel laundry work (as the Fraser Institute proposes)quite difficult to make.

THE TRADES: The work of trades persons in hospitals is distinct from work in hotels in crucial ways. These differences relate to:

• the need to have specialized knowledge of medical equipment and frequently changingand complex technologies;

• the importance of specific on-the-job experience and knowledge of hospital systems,structures and processes and the implications for patient care and safety;

• the need to frequently work in and around patients and with other professionals in thehospital; and

• the need to know how to handle hazardous materials and substances.

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30 M. A. Borg, et al, op cit, 448-50.

As noted earlier in the assessment of the Fraser Institute report, hotel maintenance work is not comparable to the work of the certified trades personnel in a hospital in terms ofyears of training and apprenticeship requirements. The higher levels of trade certificationnecessary in hospitals are clearly a result of the higher demands of the work.

RESPONSIBILITIES AND TECHNICAL KNOWLEDGETrades people who work in health care facilities need to deal with issues relating to airquality, heating, water, and medical gases. There is a much greater responsibility regardingthese issues in a hospital than in a hotel because of ahospital’s structural complexity, and the numeroussafety and quality control concerns. As an electricianexplained, the main difference between work in ahospital and work elsewhere is the need to intenselyconcentrate on the ramifications of each action. Anelectrician needs a thorough knowledge of the distrib-ution system and to be aware of how these systemsconnect to each other. If a whole section shuts off, theelectrician has to go through the drawings to knowwho and what will be affected.

This knowledge is learned in-house; it is only fromexperience on-the-job that the electrician acquiresthis information. As one electrician noted, it took himfive and a half years to learn the layout of the entirehospital where he works.

Similarly, a critical area for plumbing involves maintaining the quality of the drinkingwater. Drinking water is vulnerable to back-flow from contaminants such as radiation fromthe x-ray department. Some plumbers felt that there should be random, periodic testing ofwater quality and mandatory testing of cross-connection back-flow valves, a quality controlthat is not now carried out in all hospitals.

Another example of the specialized nature of work in a hospital is the need to ensure thatacid fumes do not contaminate medical lines for medical air treatment. Separate filtersneed to be in place to ensure that medical air treatment is safe and unpolluted. In general,trades workers in hospitals need to be – and are – extraordinarily safety conscious, notsimply because of the implications for themselves, but for the safety of patients in the hospital.

Because of the technical difficulty of hospital systems and equipment, the knowledgerequired for the job is greater than is necessary for work in hotels. A particular difficulty isthat trade workers in hospitals are constantly dealing with other professional staff and withsystems and technical equipment that change rapidly. The general requirement for tradeworkers in hospitals is a Grade B Journeyman, although most have an A ticket and mosttend to be multi-skilled. For example plumbers usually also have gas fitters and cross con-nection trade qualifications and medical gas trade qualifications are becoming a jobrequirement.

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FAST FACTS• It took one electrician

five years to learn thehospital’s entire layout

• Hospital trades people frequently “gown-up” towork around patients

• Contact with dangeroussubstances and bodily fluids is a regular part of the job

PATIENT CONTACTA major distinction between hotel workers and those in a hospital is that hotel workersrarely need to go into a room when “guests” are in them. Hospital workers often have todeal with patients being in a room, and sometimes even in a bed they are working on. Thiswas the situation described by a machinist who needed to repair an occupied bed in theintensive care unit. It requires special skill – skills that are learned on the job and comewith experience in communicating with other professionals and patients in a health caresetting. As one worker noted, “Working in patient areas where there are antibiotic resistantorganisms, or in renal areas, requires an acceptable level of decorum that is very differentfrom working on a construction site.”

In some circumstances the trades person needs to take precautions to ensure that the surroundings remain sterile. This means being conscious of where tools are placed and, insome cases, of taking universal precautions and needing to “gown-up” to ensure infectionis not spread from one area of the hospital to another.

Trades people find working on live systems that people are connected to stressful and verydemanding. This is particularly so when working in the OR during an operation or onback-up systems while a doctor is taking care of patients. They feel that the competencythis requires is not normally recognized within the hospital.

Generally, the work of trades persons is thought of as quite distinct from the “caring” professions because it is assumed that these workers perform their tasks behind the scenesand away from patients. It is, therefore, surprising to hear trades people talk about theirwork largely in terms of what it means for patients.

For example, an electrical foreman at an acute care hospital described a very simple part ofthe electrician’s job that he felt was critical for patient safety and comfort, “Some of themost trivial jobs, and the most frequent are hugely important to patients.” He gave as anexample the problem of replacing and repairing cheaply designed three-way over-headlights on beds. The switches controlling the night light, room light, and reading light areconstantly breaking. To repair them the electrician needs to negotiate around the patients,which often means negotiating around tubes and drips.

HEALTH HAZARDSHospital trades people routinely deal with dangerous substances, and contact with bodilyfluids and body parts are all part of the job. Plumbers need to be particularly aware of thecontents of drains and traps because dangerous substances like mercury and chemicals tosterilize equipment may be poured down them. The medical vacuum system often getsbacked up with contaminants, a situation that is dangerous when it is being repaired.

When plumbers repair or remove toilets, they come into contact with bodily fluids, includ-ing irradiated bodily wastes from patients receiving radiation therapy. When plumberscome in contact with cytotoxins they must gown-up, wear disposable overalls, and wearface shields to do the work. One plumber pointed out that B.C. Ferries pays an extra $8per hour for work done on gray water (sewage), but hospital plumbers are not similarlycompensated for their exposure to contaminated sewage.

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Plumbers also often come into contact with sharps that have been improperly disposed of in the sink. Almost any aspect of plumbing repair in the hospital is more dangerousthan work in a hotel. This is recognized by the special protocols that exist to control thehandling of designated substances, precautions that are outlined under provincial Workers’Compensation Board regulations. Hotel workers do not have to deal with controlled substances.

Exposure to contaminants also occurs through contact with exhaust systems, a concernthat was raised by HEU members on one hospital’s health and safety committee. Andmachinists indicate a need to know the kinds of contaminants they are breathing whenworking on exhaust fans that vent laboratories and other areas with airborne substances.

From these examples it is clear that trades workers in hospitals are exposed to dangerousconditions that are ill-defined and that are radically different from the conditions found onother worksites. Although hotel workers do encounter bodily wastes and the occasionalsyringe, they are not routinely exposed to such bio hazardous substances and infectiousagents.

CLERICAL WORKERS:31 Clerical work in health care is substantially different from clerical work in a hotel. Even work that may seem directly comparable because job titlesare similar like switchboard operator, admitting, stores, and purchasing clerks (the four positions compared with hotel workers by the Fraser Institute) – in fact has substantially different levels of responsibility. One main difference relates to the health care specificknowledge and responsibilities required of clerical workers in hospitals and long-term carefacilities.

Clerical staff are expected to have the on-the-job experience and training to deal withpatients and other health care professionals under intense stress. At the same time theymust be able to focus on the technical accuracy and details that are critical in admitting/discharging patients, creating and maintaining medical records and/or purchasing supplies.

RECEPTIONISTA clerical worker who works as a receptionist in an acute care hospital deals directly withcommunications issues in the hospital and is the main source of contact between the pub-lic and the hospital. It is a position that requires considerable health specific knowledgeand has responsibilities that are quite different from hotel reception work.

A hospital receptionist must respond to telephone inquiries when callers want specificinformation about patients, and when reporters call about accident victims or other news-worthy patients. Special skills are required to deal with aggressive reporters, or rude andanxious or unhappy people. When dealing with issues about highly public people and sen-sitive political issues, the job can be very demanding. In all cases the issue of patient confi-dentiality and safety is paramount.

The receptionist also maintains lists of patient contacts and guardians for patients who areunable to speak for themselves. Knowledge of how the hospital works is a primary require-

31 The term “clerical” is a misnomer. It includes virtually all positions that are distinct from those in housekeeping, trades, food, andlaundry. It includes admitting, switchboard, stores, and purchasing.

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ment. Since there are often no written procedures, the receptionist’s familiarity with thestaff and hospital procedures is crucial.

Receptionists often have duties that extend beyond contact with the public. One reception-ist reported duties such as releasing news reports, booking meeting rooms, answeringrequests for hospital publications, maintaining a newspaper clippings file, and takingresponsibility for communications from the president’s office, including opening mail andsending and receiving confidential faxes.

ADMITTING CLERKSAs with the receptionist, an admitting clerk requires considerable health care specificknowledge and has responsibilities that are substantiallydifferent from hotel reservation clerks. In particular, thecontact with patients and interaction with hospital unitsdemands medical knowledge that is specific to this job.The following is a snapshot of some aspects of an admit-ting clerk’s work in an acute care hospital.

Work in admissions is carried out through pre-admit-ting, main admitting, emergency admitting and terminalcase registry for discharged persons. Admitting clerks deal with everything from collectingpatient information to booking patients into the operating room or maintaining patientrecords after discharge. Often it is very challenging to obtain personal information frompatients, particularly when they are very ill or upset, or are uncomfortable with giving outthis type of information. Emergency room work is particularly difficult since it oftenrequires interviewing distressed relatives and patients at the bed side as they await medicalattention.

In addition, the responsibilities associated with accurate data collection are considerablesince this data may be vital to a patient’s treatment plan. For example a duplication error ona medical record could cause the wrong laboratory results to be attached to a patient’s chart.

In general the job requires tact, patience, experience, and flexibility. Shortages of hospitalpersonnel, like nurses, have put enormous stresses on the admitting staff. According to oneperson working in admitting, “It makes it difficult to assign beds because either beds arenot available or it is difficult to get information from the nurses. If there is a nursing short-age, beds close.”

STORESThe range and complexity of supplies in a hospital are quite different from a hotel. Thecapital equipment is more complex, the number of items that need tracking is muchgreater, and the consequences of errors are potentially lethal.

In a large acute care hospital a large number of people work in stores. At VGH, for exam-ple, 100 people deal with the shipping and receiving of approximately 10,000 differentitems – clearly an inventory that far exceeds anything in a hotel or bar. Stores receive allsupplies delivered to the hospital except blood products and pharmaceuticals. They deal

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‘It’s challenging toobtain patient datawhen they are very ill or upset’

with supplies for patient units, maintenance, security, offices, trades, cleaners, andkitchens. With regionalization, stores departments are increasingly being centralized, andthey now must deal with the complexities of supplying multiple sites.

The knowledge of stores personnel is crucial to the department’s correct functioning. Allhospital stock is coordinated through the stores department, from hip replacements tobreast implants and heart pacemakers. Workers in stores need to know what the productsare, and what to look for when requisitions are received. So, for example, when blood coilsare needed for transfusions, the stores technician needs to know not only the product’sname, but also the generic terms used, the stock number, and the catalogue name.

Sometimes there is only a digit difference in product codes – this is something that thestores person needs to know. For example, Phenokill concentrate that is used for roomcleaning is different from Phenokill for equipment cleaning, and the workers in stores arerequired to understand the difference. This knowledge comes through years of experiencein a health care setting. For example, if a dialysis unit requires a saline IV solution and glucose was sent instead, there could be serious consequences for the patient.

Also there are times when the pressure of the job is acute – particularly when there has beenan accident and a large number of patients are anticipated at short notice. According to oneworker, “stores may have only eight minutes to respond.” The quick responses are crucial.But, at the same time care needs to be taken to ensure that the seals on sterile equipmenthave not been broken and expiry dates of items like pacemakers have not passed.

Even though they do not have direct contact with patients, stores workers are acutely con-scious of the responsibility of providing life saving supplies for patient care. As one workernoted, “even if it is only one patient using a particular item, stock can be depleted.” And,depleted stock can have very serious consequence.

PURCHASINGPurchasing itself is extremely complicated and requires formal skills that are acquired boththrough professional training through courses and on-the-job training. Purchasers need todeal with both the professionals within the facility and the private sector salespeople whobid on hospital purchases. Purchasing staff are expected to have a thorough knowledgeand understanding of the products available on the market and to keep up-to-date onimprovements in technology that occur very rapidly with medical items like wheelchairs.

In addition, unwarranted delays can arise because of multiple funding sources for equip-ment purchases and complex approval processes. As a result, purchasing staff must also betenacious advocates to be effective in their work. They often take on the responsibility ofsorting through bureaucratic processes and roadblocks. As one purchaser noted, “if youjust follow your job description, then there are many things that wouldn’t get done.”

Ultimately the purchaser has to deal with units and people who are frustrated when whatthey need is not available. According to one purchaser, the “stress of working in the hospi-tal arises from having to talk to frustrated hospital managers who are waiting for theirrequests to materialize.”

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In summary, each of the clerical jobs described above – receptionist, admitting clerk, storesclerk and purchasing clerk – requires considerable specialized health care knowledge, trainingand expertise and has responsibilities that quite distinct from hotel clerical work.

FOOD SERVICE WORKERS (FSW) / FOOD SERVICE SUPERVISORS:The major difference between food service work in a health care facility and a hotel is thatin a hospital workers are dealing with dietary needs of sick people – needs that require experience in a health care setting, special awareness and knowledge of government regulations and training in the appropriate preparation, monitoring and reporting protocols. Food service work is mentally challenging, fast paced, and integral to the comfort and safety of the people within the facility. The special responsibilities associatedwith this work relate directly to the well-being and health of the patients and residents.

RESPONSIBILITIES AND SKILLSFood service supervisors and technicians take a two-year course at a community collegeand at least one person on each shift is required to have a Food Safe Level 1 certification.Each health care facility also conducts in-house training that orients workers to the specificdemands of the work within that facility.

Dietary orders for special needs patients – such as those with diabetes, heart conditions,allergies – or those who are recovering from surgery, are usually initiated by physicians anddieticians. These are often revised based on information from other health care workerswho frequently monitor a patient’s progress. This means some diets may be modified totake into account the needs of a patient who can’t to chew (i.e., when a tooth is broken) orfor some other reason is unable to eat solids.

Developing modified diets and keeping track of the “paper trail” associated with eachpatient is the job of the food service supervisor. The supervisor also monitors patients’ eating habits and food preferences. Food is labeled according to patient and location with-in the facility, a task that is the responsibility of food service workers.

Each patient has a dietary chart that for each meal indicates their food dislikes, allergies or dietary restrictions (such as gluten, salt, sugar or lactose-free) and special food require-ments such as whether the food needs to be thickened, minced or pureed. The food ser-vice worker must be familiar with each patient’s restrictions, are held accountable for allfood orders, and are expected to observe diet changes for individual patients.

PATIENT CONTACTFor most patients in hospitals meals are a high point in the day and a time for companion-ship and support. This is especially the case in long-term care facilities. In these facilities,food service workers still deliver food to individual rooms, they are able to interact withpatients and to observe whether or not patients are actually eating the food given to them.This is an important function, particularly with elderly patients.

Many food service workers are frustrated by the increased pace of work that makes themeal rushed and often leaves little time for patient contact. The result is that more traysare coming back with uneaten food. In many cases the trays for patients with swallowing

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difficulties or those who otherwise require more time to eat are left sitting on carts and arenot distributed early.

Food service workers are particularly troubled by these changes in hospital routines andare conscious of the implications this has for patients. Even small dietary issues can bevery important to people in long-term care facilities where the meals are the highlights ofan elderly resident’s day.

HEALTH HAZARDSWorking with patients who are frustrated or who have some form of dementia creates cer-tain risks. According to one worker “people delivering food to the dining room must watchout for patients who strike out, or residents with Alzheimer’s who throw food, glasses orwhatever they can reach.”

Because of the combination of the physical demands of the job and increasing workload,food service staff in long-term and acute care facilities have injury rates that are more thanthree times higher than those of the general labour force in B.C.32

IV. Key findings from the interviews withhealth care support workers

TAFF WHO PERFORM HOUSEKEEPING, laundry, trades, clerical and food servicework in the health care sector are not simply duplicating the work performed in ahotel in a different setting. As can be seen from the previous discussions, the sheertechnical sophistication of a health care facility requires different sets of skills and

responsibilities than would be required in a hotel.

It is also crucial to recognize the distinct and differentneeds that are met in a hospital. In a hotel, the workersfocus on the comfort of guests, but in a hospital the workis associated with improving the health outcomes of thepatients. Health care support workers are acutely con-scious of the health-related nature of their work and clear-ly do not see their work as simply a physical task unrelat-ed to health care delivery. Patient care relies as much on the work of ancillary support workersas it does on doctors, nurses and technicians.

In addition, it is quite clear from the discussion that support staff have acquired substantial healthcare specific knowledge and skills related to the stability of their job tenure in the hospital. Thewages and benefits paid to support workers and the job security provisions of their collectiveagreement encourage a stable workforce. An employment strategy, like contracting out, thatundermined these wages and working conditions could lead to long-term problems associated

S

32 Kitchen workers in long-term care facilities and acute care hospitals have injury rates of 15.5 per cent compared with 4.1 per cent for the average worker in the labour force. (Workers’ Compensation Board, Statistical Services, special run, 1999).Theirinjuries come from repetitive strains from working on a tray line, cutting food during food preparation, and musculoskeletel strainsfrom maneuvering heavy food carts.

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‘Patient care relies asmuch on supportworkers as it does ondoctors, nurses’

with high turnover rates, lower quality and the need for an increase in administrative and supervi-sory staff to supervise and monitor contractors and to train and support inexperienced staff.

V. Experiences with contracting out in other jurisdictions

HE PREVIOUS SECTION SHOWED THAT support work in hospitals is not equivalentto hotel work and, therefore, should not be treated as though it is. It also showed thatthe work of support workers is an integral part of the efficient functioning of a hospi-tal. This section will examine the experiences of hospitals that have treated these ser-

vices as though they are “hotel” services and contracted out the work to private service compa-nies. The experiences of U.S. hospitals will be examined because they have gone further thanCanadian hospitals in privatizing the provision of theseservices. A discussion of the Toronto Hospital will alsobe included because it is a Canadian example of whatcan happen to public institutions when support work-ers are not directly employed by the hospital.

THE U.S. EXPERIENCE: Outsourcing or con-tracting out refers to the management technique of shifting various operations of an institution to the private sector.33 The main reason institutions con-tract out is to either cut labour costs or to provide specialized expertise that regular staff do not have.A 1999 large survey of 340 acute care hospital executives in the U.S. by the Hospitals & Health Networks indicates that both clinical functionsand support services are contracted out.34 While the normal justifications for contracting out support services are that these are “hotel-like” functions that can be more cheaply performed by for-profit firms (as the Fraser Institute asserts), an examination of outsourcing in the U.S.indicates that these “hotel-type” services are not outsourced in most hospitals.

The survey, undertaken by the Hospitals & Health Networks, indicates that only four support services (out of 30 listed) are contracted out by the majority of the U.S. hospitalssurveyed. These are pest control (86 per cent), laundry/linen (62 per cent), patient satis-faction measurement (61 per cent) and waste management (58 per cent).35 Less than one-

33 For a discussion of the theory and practice of contracting out in the U.S. see Paul Seidenstat, ed., Contracting Out GovernmentServices, Privatizing Government (Westport, CT; London: Praeger, 1999).

34 Sunseri Reid, “Ninth Annual Contract Management Survey,” Hospitals & Health Networks 1999 73, no. 10 (October 1999).Theclinical functions that are most frequently outsourced are equipment maintenance (58 per cent) dialysis (45 per cent), and anesthe-siology (38 per cent).

35 Ibid., Figure 2.The figures in brackets indicate the proportion of hospitals that have contracted out this service.

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T

FAST FACTS• Surprisingly, “hotel-type”

services are not contractedout in most U.S. hospitals

• Thirty-two per cent contract out food servicesand just 27 per centhousekeeping

• Toronto Hospital bringsfood services in-houseto cure widespreadpatient disatisfaction

third of the hospitals outsource food services (32 per cent) and just 27 per cent outsourcehousekeeping. Only 16 per cent outsource facility maintenance and virtually none out-source stores, admitting, and other clerical-related work. The survey indicated that themove to outsourcing “appears to have peaked.”

The primary motivations for outsourcing cited by executives are:

• to reduce costs (33 per cent); • obtain specialized expertise (33 per cent); and • allow the hospital to focus on “core competencies” (20 per cent).

On the other hand, those administrators who have decided not to outsource explained thisdecision on the basis of three main factors:

• they run the department well themselves (81 per cent); • it is less expensive if done in-house (59 per cent); and • they fear the loss of control over the function (49 per cent).

Caution about the benefits of outsourcing is certainly warranted, as is indicated byresearch on hospital “re-engineering” in the U.S. Re-engineering refers to changes in organizational practices. In the case of health care facilities it usually involves contractingout, although it can encompass a variety of dramatic changes in work processes thatinvolve the reallocation of work flows, job responsibilities and production design.

To understand whether re-engineering in hospitals significantly improves the economicposition of the organization, the American Hospital Association conducted a survey ofapproximate 30 per cent of all U.S. acute care hospitals with 100 or more inpatient beds.36

The main findings of this study indicate that there is no reason to be optimistic about thebenefits of re-engineering – “re-engineering appears to increase hospital costs relative tocosts of competitors.”37 In general the survey found that “re-engineering not only may notimprove performance, but may actually be detrimental to it.”38

THE TORONTO HOSPITAL: In the fall of 1993 the Toronto Hospital (part of the university hospital network, Canada’s largest health care facility) began privatizing hospital support services. It was an ambitious attempt to reduce the hospital’s operating costs and to improve the quality and productivity of its services.39 Senior management firmly believed that through outsourcing, “support service functions of the hospital could becarried out at less cost with no reduction in quality or levels of productivity.” Managementof house-keeping was contracted out as were food services and stores.40

In its Hospital Report 99, the Ontario Hospital Association undertook a comprehensive survey of Ontario hospital efficiency. It looked at efficiencies in a broad sense arguing that,

PAGE 23

36 Stephen Lee Walston, Lawton Robert Burns, and John R. Kimberly, “Does Re-engineering Really Work? An Examination of theContext and Outcomes of Hospital Re-Engineering Initiatives,” Health Services Research 34, no. 6 (February 2000): 1363-1388.

37 Ibid., 1374.38 Ibid., 1379.39 James A. Stonehouse, Alan R. Hudson, and Michael J. O’Keefe, “Private-public Partnerships: the Toronto Hospital Experience,” in

Strategic Alliances in Health Care: A Casebook in Management Innovation, ed. By Peggy Leatt, Louise Lemieux-Charles, Catherine Aird,and Sandra Leggat. (Ottawa: Canadian College of Health Service Executives 1996): 137-147.

40 Ibid., 139.

“for too long our health care system has been measured from the rather narrow perspectiveof cost management alone, with less regard to clinical outcomes and patient satisfaction.”41

As a result, patients were asked how satisfied they were with a range of services in the hospital, including support services. Questions about support services included queriesabout food quality and service. Patients were also asked about housekeeping, specificallywith regard to the cleanliness of their rooms, bathrooms and the hospital in general.

Patients, on the whole, were not satisfied with the services at Toronto Hospital. Patientsatisfaction with housekeeping (which had contracted-out its management) was rated as“below average” performance, while support services overall were considered to be at thevery best, “average.” The survey is too blunt an instrument to be able to discern specificresponses to issues like the quality of food or why housekeeping is considered below average. But clearly there are some grounds for concern.

In 1999 a survey of Toronto Hospital employees was also undertaken by hospital manage-ment to ascertain employee satisfaction. It was more decisive. Employees had a variety ofquestions with regard to leadership and direction, work involvement, work demands,teamwork, physical surroundings, financial rewards, career future and security and theircommitment to the organization. The survey determined that staff below the senior man-agement level were very unhappy with work in the facility, and the hospital was found tobe below average in almost all areas surveyed. (The comparison group was a database of100,000 employees in many industries across North America.)

In the reporting of the survey and as a guide to interpreting the results, the authors con-structed an “Alienation Index” (AI) from Toronto Hospital responses in order to measureemployee satisfaction. Low scores on the AI were deemed to be “highly predictive of employ-ee withdrawal behavior such as voluntary turnover, absenteeism and third party interven-tion.”42 A low score would be one that fell between -4 and -25 and would indicate a seriousdegree of alienation and acute employee disengagement. The vast majority of groups in thehospital had AIs that were very negative. The following are examples of the responses:

GROUP ALIENATION INDEX

Medical staff physician -12

Registered nurse -11

Licensed Practical Nurse (LPN) -7

Six to 10 years at hospital -11

Clerical -4

Technologist -16

Technician -8

Hospital assistant (support worker) -15

Ward aide (care aide) -9

PAGE 24

41 Ontario Hospital Association, Hospital Report 99: A Balanced Scorecard for Ontario Acute Care Hospitals (Toronto: OntarioHospital Association, 2000).

42 Organizational Studies Inc., Total University Health Network. (Organizational Studies Inc., October 1999), ii.

It is not clear – from either the patient satisfaction survey or the survey of employees –why the hospital performed so badly on these issues. Although the surveys do not link thepoor scores directly to contracting out, the information collected in interviews withemployees at the Toronto Hospital suggests that there is a very clear connection betweenthe two.

In order to learn about the staff’s experience with re-engineering and contracting out, several interviews were conducted with nurses and housekeeping staff at Toronto Hospital.Their analysis of the difficulties with contracting out and re-engineering focuses on foodservices and stores – the two support services that were contracted out in the mid 1990s.

FOOD SERVICEIn 1994, dietary services were contracted out through the Toronto-based Bitove Corpor-ation. According to one report this change would potentially save the hospital $2.5 mil-lion, or half a per cent of its total operating budget.43 While the cost savings are somewhatspeculative, the deterioration in the food quality is not.

The contracting out of food preparation and delivery resulted in a “cook-chill” system thatfeatures highly processed and highly packaged food, the elimination of hot breakfasts,elimination of water delivery to patients and delays in meeting the needs of new patientswith special dietary needs.44 As one hospital worker noted, the highly packaged food isparticularly difficult for old and sick people to open. Even a piece of toast is heat-sealedand many patients cannot open it. “The cold breakfast, often a bagel with peanut butter, isa horrible encounter for people with dentures,” one caregiver noted.

Often, food delivery schedules would go awry. One Monday, after a long weekend, thehospital ran out of food. Apparently the food supplier had failed to take into account thatthere would be a large intake of patients for surgery after a long weekend. The hospital,fortunately, had returned to making salads and sandwiches on-site after having contractedit out, so a very difficult situation was averted. However, even with this backup, one wholegroup in the hospital had no food for a day.

The Toronto Hospital is about to go through massive renovations and new building. Theplan is to build new kitchens and bring back the dietary work in a dramatic reversal of theprevious decision to contract out food services.

STORESAn outside contractor handles all the stores supplying the three facilities in the universityhospital network, including Toronto Hospital. The problems with the contracting out ofstores relate primarily to the inability to have supplies when needed because very few sup-plies are kept in the hospital. Each floor has a quota of supplies that is insufficient for its

43 Stonehouse, et al, op. cit., 140; Financial Statements,The Toronto Hospital, March 31, 1996. It is difficult to tell from the reportingwhether this was the actual savings or the savings that were promised through the contract.

44 CUPE, Cooking Up a Storm: Shared Food Services in the Health Care Sector, CUPE Research, 1995. In a conventional hospital foodsystem meals are prepared a few hours in advance by staff within the hospital and held at the desired temperature (also calledcook-hot-hold).The cook-chill method used by Bitove is radically different in that it allows for longer storage periods through con-trolled chilling and vacuum packaging process.While there is considerable debate about whether these processes actually reducecosts, it is clear that they do reduce food quality.

PAGE 25

needs, so hoarding becomes routine. Quotas are allocated according to a complex systemwith penalties that ensure minimal supplies are ordered. Also, the supplier can determinesubstitutes for ordered items and even if no one on the unit can use them, they are stillcharged to the unit.

There are numerous examples of how the privatized stores system negatively impacts onpatient care. In one case a doctor on a cardiac outpatient floor wanted the diapers of anincontinent patient weighed regularly in order to determine her fluid retention. The floorhad run out of adult diapers and the stores supplier, when contacted, could not delivermore for 24 hours, and even that service would cost an extra $100. Other floors could notaccommodate the request, and the result was that this “procedure” was discontinued.

In another case the use of “blue pads” (i.e., for incontinence) that are crucial to patientcomfort, have been curtailed. Now patients do not necessarily have clean pads when theyshould. As one worker said, “There have been no good times since 1994 when stores wasoutsourced.”

Evidence from the Toronto Hospital experience raises questions as to whether the benefitsfrom contracting out outweigh the costs. Contracting out may, in fact, have been responsi-ble for a reduction in patient and staff satisfaction. The recent reversal on contracting outof food services points in this direction.

As a McMaster University study noted, too often “Hospitals in both the U.S. and Canadahave embarked on re-engineering strategies in the absence of empirical evidence that it iseffective or safe for patients.”45 Until there is further analysis on why patients and workersare so dissatisfied with their hospital experience, the re-engineering and contracting outexperience that the Toronto Hospital undertook in 1994 should not be used as a templatefor other hospitals.

VI. The privatization agenda HE FRASER INSTITUTE ADVOCATES OUTSOURCING hospital support services as away of saving money. It does not argue that there are greater efficiencies to be made,rather, that one group of workers – health care support workers – are paid too muchfor what they do.

But this is not the end of the story or the whole story. The Fraser Institute is clearly intent onseeing that the entire hospital sector is privatized. Their recent report, How Private HospitalCompetition Can Improve Canadian Health Care, claims “private hospitals can lower costs byavoiding the high wages associated with unionized public hospital employees in non-healthcare positions.”46

PAGE 26

45 Christel Woodward, Harry S. Shannon, Charles Cunningham, John McIntosh, Bonnie Lendrum, David Rosenbloom, and J. Brown,Re-engineering in a Large Teaching Hospital: A Longitudinal Study,Working Paper Series (Hamilton, ON: McMaster University, 1998),98-1.

46 Martin Zelder, How Private Hospital Competition Can Improve Canadian Health Care, On Public Policy Source Papers 35(Vancouver:The Fraser Institute, 2000).

T

It is worth examining this assertion, particularly with regard to the expenditures of private U.S.hospitals on supposedly “hotel-like” services.47 According to an editorial in the New EnglandJournal of Medicine “no peer reviewed study has found that for-profit hospitals are less expensive[than not-for-profit hospitals.]”48 The higher costs of profit-oriented hospitals are a result ofgreater expenses for administration and support services.

In fact there is considerable evidence to indicate that theprivatization of hospitals leads to more expensive “hotelservices.” According to one U.S. health analyst, U.S. hospi-tal support services cost more per day or unit of servicethan they do in Canadian acute care facilities.49 The lowercosts among Canadian hospitals are predictable because oftheir global budgetary targets and single-payer system. Butin addition to higher cost of processing claims in the U.S.system, the study also found that competition amongAmerican facilities for increased market shares result in“providing patients with more expensive hotel services.” 50

The rush to privatization in hospitals has little to do withdiscussions of relative efficiencies or even cost cutting. Theevidence simply does not support the notion that the ben-efits will be substantial and the costs considerably lower.There are hidden costs of privatization and sacrifices to both patient health and staff morale thatshould make administrators very wary of calls for privatizing hospitals services. The splitting ofclinical and nonclinical work where it has occurred (i.e., in Britain and in the Toronto Hospital)creates “institutional apartheid” that can be detrimental to staff morale and the care ofpatients.51

Outsourcing of support services is clearly a step in the market-driven direction the FraserInstitute advocates for hospitals, and they are following a clear strategy that is well-known tothe supporters of privatization. The political path toward privatization is not easy, since peopleclearly recognize the value of publicly provided health care. But, according to one theorist ofcontracting out, the process needs to proceed in a step-by-step fashion in order to succeed,“Privatization efforts are most likely to proceed in an ad hoc, piecemeal, opportunistic fashion... Rapid, comprehensive, wholesale efforts to privatize are not likely to be embraced by electedofficials or by masses of voters.”52

47 It should be noted that the studies used by the Fraser Institute to support this claim are too dated to be considered appropri-ate for contemporary comparisons. According to Kevin Taft & Gillian Steward, the Fraser Institute also tended to misrepresent whatthe studies actually found. See Taft & Steward, Clear Answers:The Economics and Politics of For-Profit Medicine (Edmonton: DubalHouse & Parkland Institute, 2000).

48 Steffie Woolhandler and David U. Himmelstein, “When Money Is The Mission:The High Costs of Investor-Owned Care,” TheNew England Journal of Medicine 341, no. 6 (August 1999).

49 Thomas P.Weil, “How Do Canadian Hospitals Do It? A Comparison of Utilization and Costs in the United States and Canada,”Hospital Topics (Jan. 1995): 10-22.

50 Ibid., 7.51 Paula Hall, “Warning Over Staff Transfer : Concern as City’s Super-hospital Draws Near,” Coventry Evening Telegraph, 18 March

1999.52 Paul Seidenstat, “Theory and Practice of Contracting Out in the United States,” in Seidenstat, op. cit., 19.

PAGE 27

FAST FACTS• Studies suggest private

hospitals lead to morecostly “hotel” services

• Support services costmore per day in U.S.hospitals than in Canada

• Privatization supporterspreach a piecemealapproach to avoid publicopposition

The Fraser Institute seems to have heeded this warning and understands that the public will bealarmed if a political discussion of the entire privatization of the hospital sector is at issue.What they are intent on doing, at least in B.C., is to argue for the logic of privatizing hospitalwork one step at a time. Their first target is support work. If the arguments of the FraserInstitute are successful, it will be an incremental step toward the ultimate goal of the privatiza-tion of the hospital sector.

The Fraser Institute has pursued its privatizing objectives in the hospital sector on the basis of aseriously flawed report on the cost comparisons between support workers in hospitals and hotelworkers. As this study has shown, the responsibilities, skills and conditions of work of hospitalsupport workers are radically different from that of hotel workers and cannot be compared inthe ways that the Fraser Institute and other supporters of privatization do. The benefits claimedfrom privatization appear to be driven more by ideological objectives than by an examination ofthe actual experiences of hospitals in either the U.S. or Canada.

In recent years, health care reform has increasingly focused on integrating the various aspects ofhealth care. Health care providers recognize that each aspect of patient care is related to thewhole program for the successful treatment of a patient. Any attempt to privatize and fragmentaspects of that care runs counter to the notion that health care systems need to be integrated.Privatization of any part of the health care system will simply fragment care and put barriers inthe way of teamwork.

PAGE 28

Appendix I

Wage Comparisons: Trades Occupations

Electrician Painter Plumber Carpenter

School Board 1 27.05 26.43 27.03 -

BC Hydro (IBEW) 26.34 24.45 24.45 -

College (BCIT - CUPE) 25.07 - 23.86 23.12

Government (BCGEU) 23.84 22.18 - -Facilities Health Support Workers (HEU) 24.83 22.44 24.50 23.63

IUPAT 2 (construction) - 25.21 - -

IUPAT (residential) - 23.25 - -

IUPAT (industrial) - 26.25 - -Carpenters Union 3 (comm. & inst.) - - - 24.45Carpenters Union (industrial) - - - 26.35

1 Electricians with IBEW 213; Painters with PATU; Plumbers with PPU.2 International Union of Painters and Allied Trades, district council 383 Carpenters and Joiners United Brotherhood of America

Page 29

Rate March 31, 2001

10/29/01

Appendix I

Wage Comparisons: Support Occupations

Maintenance Worker III

Clerk V Purchasing Secretary

Clerk II/ Receptionist

Switchboard Operator

Food Service Worker I

Food Service Worker II (Cook's Helper) Cook I

Housekeeping Aide Cleaner

Laundry Worker I

School Board - 22.87 19.29 18.12 17.00 - - - - 18.21 -

BC Hydro - 21.47 19.68 19.68 19.68 - - - - - -

ICBC (OPEIU) 18.30 18.30 19.71 17.00 17.00 - - - - 17.00 -

College (BCIT - CUPE) 24.83 18.80 18.80 17.91 17.91 - 16.85 19.87 - 16.00 -

Government (BCGEU) 18.49 20.87 18.49 17.41 18.49 18.38 18.49 19.64 16.90 16.90 16.90Health Support Workers (HEU) 19.78 21.13 19.03 16.97 18.98 17.41 17.07 19.53 17.19 17.19 17.17

BC Ferries (FMWU) - - - - - 16.77 19.24 20.67 - - -

Delta Pacific Hotel 16.01 - - - 14.03 - 14.23 15.73 14.11 14.37 14.06

Westin Bayshore Hotel 18.08 - - - 14.98 - 15.07 15.84 15.09 15.21 15.02

Page 30

Rate March 31, 2001

School Board (CUPE Local 18) BC Hydro (OPIEU), ICBC (OPIEU), BCIT (CUPE), Government (BCGEU), Facilities Health support (HEU), BC Ferries (FMWU), Bartenders (Local 40), Westin Bayshore Hotel (Local 40)

10/29/01

Appendix IIInterview Methodology

Interviews for this study were conducted between September 2000 and January 2001. Much of the information about ancillary hospital support work was obtained through interviews with30 hospital workers during six focus-group interviews in November 2000. The focus groupsconsisted of workers associated with housekeeping, clerical work, trades and maintenance,nutrition services and laundry work. These groups also represented workers in six acute carefacilities, seven long-term care facilities and one laundry.

The acute care hospitals represented are Vancouver General Hospital, Royal ColumbianHospital, St. Vincent’s Hospital, Surrey Memorial Hospital and Eagle Ridge. The long-term carefacilities represented are Youville Residence, Cooper Place, Ridge Meadows, Fellburn CareCentre, Glengarry in Sooke and the long-term care facilities at St. Vincent’s Hospital and EagleRidge. Workers at the Tilbury Laundry were also interviewed. The focus of interviews withHEU members was to gain insight into the work of support personnel with particular referenceto the skills, effort, responsibility and working conditions.

In addition to HEU members, other hospital personnel and health experts were interviewed forinformation about health and safety issues, the work of hospital support personnel, training andeducation and information about contracting out at the Toronto hospital. These included thefollowing:

• Senior infection control nurse at a B.C. acute care hospital;

• Medical microbiology physician at a B.C. acute care hospital;

• Health and safety physician, B.C. Workers’ Compensation Board;

• Electrical foreman at a B.C. acute care hospital;

• Business agent, Hotel, Restaurant and Culinary Employees and Bartenders Union Local 40;

• Instructor, Building Service Worker Program, Vancouver Community College;

• Instructor, Institutional Aide Program, Vancouver Community College;

• CUPE local president, Toronto;

• Occupational health and safety RN, Toronto Hospital;

• OR nurse, Toronto Hospital;

• Two health care analysts; and

• Health analyst, Department of Soil, Water and Environment Sciences, University of Arizona.

PAGE 31

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